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April 18, 2011 -- People with do-not-resuscitate (DNR) orders may be more than twice as likely to die soon after surgery, regardless of the urgency of the procedure or health status before surgery.

A new study shows 23% of people with DNR orders died within 30 days after surgery compared with 8% of similarly matched surgery patients without DNR orders. They were also more likely to suffer serious complications and have longer hospital stays.

Researchers say it's the first study to look at the effect of DNR status on surgical results. For every type of surgical procedure analyzed, they found people with DNR orders fared worse than those without them.

Experts say to a certain extent, the results are not surprising because people with DNR orders tend to be much sicker to begin with and would be expected to fare worse after surgery. But the study also raises the question of whether a DNR order changes the way doctors and nurses treat patients.

"If I were a patient, I might worry from this study that having a DNR on my chart might lead to less aggressive treatment," says Clarence Braddock, MD, MPH, professor of medicine and associate dean of medical education at Stanford School of Medicine.

DNR Status Affects Surgery Results

In the study, published in the Archives of Surgery, researchers compared clinical information on 4,128 adults with DNR orders and a comparison group of 4,128 age- and procedure-matched adults without DNR orders who had surgery at one of 120 U.S. hospitals from 2005 to 2008.

The results showed that nearly one in four people with DNR orders died within 30 days of surgery, more than twice the rate found among those without DNR orders.

Most of the people with DNR orders (63%) had non-emergency surgical procedures. But regardless of the urgency of the procedure, the study showed people with DNR orders were two times more likely to die soon after surgery.

"They start out sicker, that's true," says researcher Sanziana Roman, MD, associate professor of surgery at Yale University. "But if we take that into account and take it out of the equation, we still found DNR was on its own was an independent risk factor for death."

DNR Orders Misinterpreted?

A do-not-resuscitate order is a legal form instructing health care providers that cardiopulmonary resuscitation (CPR) and other measures should not be performed in the event that the patient’s heartbeat stops.

But Braddock, who is also director of clinical ethics at Stanford's Center for Biomedical Ethics, says some health care providers can take the intent of a DNR order even more broadly. He says previous studies have also shown that DNR orders subconsciously affect how doctors and nurses treat patients. For example, they order fewer tests and don't enter the patient's room as often.

"I do not believe that most patients, as part of the informed consent process around DNR, are aware that it might inadvertently lead to less intensive care," says Braddock.

Frank DNR Discussion Needed

That's why researchers say it's important for patients to talk to their doctors not only about DNR status but the bigger picture of the goals of their treatment and care.

"If someone says, 'If my heart stops, I don't want it to be restarted,' that is one thing, but if they say something broad like, 'I don't want you to use extreme measures,' What do extreme measures mean? I think that is fuzzier," says Roman.

"It is important to have the conversation in more detail between physician and patient," says Roman. "So physicians can understand their patients' wishes better, and the patient understands the risks and outcomes better by knowing what to expect if certain things happen."

Some experts also say it would be a mistake to misinterpret the study results as saying DNR status automatically means a worse prognosis after surgery for everyone.

"For patients who do decide to become DNR, this study shows outcomes for surgery are significantly less," says J. Randall Curtis, MD, MPH, professor of medicine at the University of Washington, Seattle. "That doesn't mean surgery is not worth trying necessarily, but it is important to understand that it is riskier than for patients who are healthier."

Researchers say the use of DNR orders has been increasing in recent years, and up to 15% of people with a DNR have surgery.

Curtis says that is a trend that is likely to continue and underscores the need for patients to have a frank discussion about their wishes with their health care providers prior to surgery.

"More and more patients, particularly with chronic illness or advanced age, are saying 'I don't want all of this' under normal circumstances, 'I only want it if I can achieve the goals that I would find acceptable.'" says Curtis.